This paper will analyze data from a patient’s health history and develop a nursing care plan.
Analysis of Assessment Data
Areas for focused assessment
The patient’s areas of strengths were:
- Health patterns and goals
- Health care beliefs and practices
The patient’s areas of weakness were:
- Family history
- Past health history
- Emotional problems.
- Ethnicity and culture
Health patterns and goals
The patient’s health enhancing behaviors were regular exercising and taking a nutritious diet with no calories and little salt. Health patterns are habits and traits that affect a patient’s health directly or indirectly. According to D’Amico and Barbarito (2012) health patterns “play key roles in the patient’s total health history because it is the lifestyle thread that, woven throughout the fabric of the health history, gives depth, detail and definition” (p. 170). When conducting an assessment, nurses compare a patient’s health patterns to predetermine any relationship with their health state.
Health care beliefs and practices
The patient believed that health care was provided by medical personnel, and associated the cause of diseases with bacteria and germs. His health care decisions were influenced by the availability of information on health related issues and cultural beliefs on the needs to seek medical care from doctors. The patient also attended frequent health checkups. Perceptions about factors contributing to illnesses have impacts on the health state of individuals. Cultural experiences and exposure to information influence an individual’s health care beliefs and practices (D’Amico & Barbarito, 2012).
Areas of concern
The patient’s family had an history of illnesses. His mother suffered from bi polar disorder and obesity. The father suffered from hypertension. His paternal grandparents also suffered from hypertension. This could explain how the patient acquired hypertension and bipolar disorder. People from families with a history of certain diseases highly risk contracting the diseases. Family dynamics also help nurses in learning approaches to a patient’s health care (D’Amico & Barbarito, 2012). Thus, the patient is exposed to high risks of contracting illnesses such as diabetes.
Past health history
Past health history revealed that the patient had suffered a mild stroke and had obesity and hypertension illnesses in childhood. Assessment of past health history equips nurses with information that can be used to link any medically related conditions. This helps in diagnosis and treatment of present illnesses as it provides information on previous medical conditions and medications used where applicable (D’Amico & Barbarito, 2012).
The patient had mental, emotional and psychiatric problems. He suffered from Bipolar disorder and had memory lapses. Psychological and emotional factors affect the physiological health of an individual ‘(D’Amico & Barbarito 2012). Problems related to psychology and emotions may also interfere with a patient’s medication and assessment.
Ethnicity and culture
The patient was an African American. His social environment was associated with overweight people and poor diets practices. Thus, the physical environment and his ethnicity placed him at a risk of contracting health related illnesses. Cultural practices influence health decisions of individuals. Ethnicity also plays a key role in determining health factors of individuals due to shared genetic and biologic disorders. For example, people from African American ethnicity face high risks of contracting hypertension (D’Amico & Barbarito 2012).
Health teaching topics
The patient was concerned about the prevalence of illnesses in the family and asked questions about the genetics behind his condition. Also, he was not aware of the risks of psychological and emotional health on his illness. He also complained about several changes in his cardiac system after taking previous medications. From the assessment, the patient had knowledge deficiencies in the following areas:
- Family history and genetic factors
- Effect of emotional disturbances to physical wellness
- Side effects of medication such as diuretics
- Risks of current medical condition
In this case, application of informal instruction is important. The teaching process includes provision of instructions to patients to create health wellness. Nurses also answer patient’s questions (D’Amico & Barbarito 2012).
Nursing Care Plan
Hypertension (P) related to genetics, depression and obesity (E) as evidenced by severe and persistent headaches, blurred vision, nose bleeding and loss of breath (S).
The plan’s main goal is to help the give the patient psychological therapy and medicines. The outcome of this would be a regulated blood pressure system. This would be the first step because high blood pressure exposes the patient to heart diseases. The cases of hypertension among African Americans rise daily.. Research should also be carried to determine the popularity of hypertension among African Americans and preventive measures adopted.
Nurse order 1: First Diagnosis
Hypertension caused by depression and obesity.
Observations: B/P: 140/90, Weight – 92Kgs
- Thalitone: 15 mg/Kg/ x 1 to help the body to get rid of extra water and salt.
- Tenormin: 50 mg/ kg/ x 1 to lower the heartbeat rate, hence regulate blood pressure though vessels.
- Trandolapril: 2 mg/kg/ x 1 to inhibit the secretion of angiotensin enzymes that narrow blood vessels
Intervention: 1. Observe low calorie diet. 2. Reduce weight to 90kg 3. Take medications
Appointment: After a month
Nurse Order 2: First Visit
Observations: B/P:120/ 90, Weight: 91Kgs
- Notes: Medication was well observed
- The patient observed a strict diet
- Patient’s progress in reducing body mass is god
- The patient still experience extreme mood disorders
- Noted increase in headaches and dizziness
- Intervention: 1. Referred to psychiatrists for bipolar therapy and treatment
- Appointment: After a month
To evaluate the effectiveness of the wellness program, I would look out on the patient’s the psychological health and stability of blood pressure. The psychological health of the patient will determine the stability of blood pressure. Stable blood pressure reduces chronic illnesses associated with hypertension.
D’Amico, D., & Barbarito, C. (2012). Health and physical assessment in nursing (2nd ed.). Upper Saddle River, NJ: Prentice Hall.